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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313623374
Report Date: 12/09/2020
Date Signed: 12/09/2020 03:42:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:PONCE, ROSANAFACILITY NUMBER:
313623374
ADMINISTRATOR:PONCE, ROSANAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 259-1888
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:14CENSUS: 7DATE:
12/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rosana PonceTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Jeremey McClain conducted a Tele-Inspection via Facetime with Licensee Rosana for an unannounced Case Management Inspection. Seven children were present during the inspection, as well as her assistant Rocio Maurizo.

An incident report was received on December 12, 2020 that stated on 11/30/2020 a child in care fell off a chair in the play area of the home. The child was taken to the hospital the following day and was diagnosed with a broken arm and given a cast. The child has since returned to the care. LPA observed the area the incident happened in and didn’t observe any safety hazards. The chair that the child fell from what appropriate for their age, and there was also cushioning. LPA also interviewed assistant Rocio who was present during the incident.

LPA determined that there were no violations of Title 22 Regulations as a result of the incident.

A copy of this report was emailed to licensee for review and signature. LPA also provided a Notice of Site Visit, which must remain posted for 30 days.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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